Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix Applies to the following Tufts Health Plan products: ☒ Tufts Health Plan Commercial (including Tufts Health Freedom Plan)1 ☐ Tufts Medicare Preferred HMO (a Medicare Advantage product) ☐ Tufts Health Plan Senior Care Options (SCO) (a dual-eligible product) Applies to the following Tufts Health Public Plans products: ☒ Tufts Health Direct (a Massachusetts Qualified Health Plan [QHP]; a commercial product) ☒ Tufts Health Together (a MassHealth MCO Plan and Accountable Care Partnership Plans) ☒ Tufts Health RITogether (a Rhode Island Medicaid Plan) ☐ Tufts Health Unify (OneCare Plan; a dual-eligible product) Note: Audit and disclaimer information is located at the end of this document. The matrix below contains all of the CPT codes for which NIA will authorize on behalf of Tufts Health Plan. The CPT codes for interventional pain management (IPM), spinal surgery and joint surgery services are subject to prior authorization by NIA. Certain procedures, items and/or services may require referral and/or prior authorization. While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you must confirm that prior authorization has been obtained. Tufts Health Plan does not compensate add-on codes (prefixed with +) if the primary procedure code has not been submitted for the same date of service. Add-on codes pertain to services performed in conjunction with a primary procedure and should never be reported as a stand-alone service. Refer to the AMA CPT manual for additional information. INTERVENTIONAL PAIN MANAGEMENT: OUTPATIENT² If a procedure from the allowable billed groupings is billed, and a valid authorization number for the corresponding authorized CPT procedure code has been issued within the date of service validity period, the service is eligible for coverage, subject to the provisions of the member’s benefit plan document. Services for IPM rendered as part of emergency department (ED) services, observation services or in a hospital inpatient setting, are not subject to prior authorization. If the billed CPT code does not match a corresponding CPT code from the allowable billed groupings, the claim will deny and the member is not responsible. Procedure Primary CPT Code Allowable Billed Groupings Cervical/thoracic interlaminar epidural 62321 62320, 62321, 64479, +64480 Cervical/thoracic transforaminal epidural 64479 62320, 62321, 64479, +64480 Lumbar/sacral interlaminar epidural 62323 62322, 62323, 64483, +64484 Lumbar/sacral transforaminal epidural 64483 62322, 62323, 64483, +64484 Cervical/thoracic facet joint block³ 64490 64490, + 64491, +64492 1 Commercial products include HMO, POS, PPO, USFHP, Tufts Health Freedom Plan, and CareLinkSM when Tufts Health Plan is the primary administrator. 2 Add-on codes do not require separate authorization and are to be used in conjunction with the approved primary code for the service rendered. 3 The following CPT codes for procedures performed with ultrasound guidance are not a covered service and are nonreimbursable: 0213T, +0214T, +0215T, 0216T, +0217T, +0218T Revised 08/2021 1 Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix Procedure Primary CPT Code Allowable Billed Groupings Lumbar/sacral facet joint block³ 64493 64493, +64494, +64495 Cervical/thoracic facet joint radiofrequency 64633 64633, +64634 neurolysis Lumbar/sacral facet joint radiofrequency 64635 64635, +64636 neurolysis Note: Due to the repeat nature of IPM procedures, multiple authorizations may exist within the same validity period. LUMBAR AND CERVICAL SPINE SURGERY² If a procedure from the allowable billed groupings column is billed and a valid authorization number for the corresponding authorized CPT procedure code has been issued within the date of service validity period, the service is eligible for coverage, subject to the provisions of the member’s benefit plan document. Spinal surgery services rendered as part of ED services are not subject to prior authorization. For procedures performed in an inpatient setting, inpatient notification is required from Tufts Health Plan in addition to the appropriate authorization from NIA. Spinal deformity surgery does not require prior authorization. If the billed CPT code does not match a corresponding CPT code from the allowable billed groupings column, the claim will deny and the member cannot be held responsible. Note: Spine surgeries typically have more than one CPT associated with each case and often times a decompression is performed during the fusion surgery; in these instances, both will be billed. LUMBAR SPINE SURGERY These codes do not require prior authorization. If the main surgical procedure is Authorization is provided for the primary surgery requested. approved, these codes are There are multiple CPT codes that can be associated with each procedure. understood to be These are assumed to be part of the primary surgery request and when included in completed in combination, do not require a separate prior authorization. conjunction and do not require prior authorization. Note: This is not an all-inclusive list of every ancillary code Primary Additional Primary Primary Surgery Ancillary Other Covered Surgery CPT Allowable Procedures / Procedure Procedures / Request Code Billed Codes Names Codes Groupings Lumbar 62380, 63030, 63030 Discectomy Microdiscectomy +63035 63005, 63012, 63017, 63042, Microdiscectomy: Laminectomy, Lumbar 63047 +63044, 63047, 62380, 63030, Laminotomy, Decompression +63048, 63056, +63035 Foraminotomy +63057 Revised 08/2021 2 Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix LUMBAR SPINE SURGERY These codes do not require prior authorization. If the main surgical procedure is Authorization is provided for the primary surgery requested. approved, these codes are There are multiple CPT codes that can be associated with each procedure. understood to be These are assumed to be part of the primary surgery request and when included in completed in combination, do not require a separate prior authorization. conjunction and do not require prior authorization. Note: This is not an all-inclusive list of every ancillary code Primary Additional Primary Primary Surgery Ancillary Other Covered Surgery CPT Allowable Procedures / Procedure Procedures / Request Code Billed Codes Names Codes Groupings Instrumentation: Microdiscectomy: +22840, +22841, 62380, 63030, +22842, +22845, +63035 +22853 ALIF, TLIF, 22533, 22558, Decompression: Bone Grafts: Lumbar Fusion PLIF, XLIF, 22612 22612, 22630, 63005, 63012, +20930, +20931, (Single Level) OLIF, Postero- 22633 63017, 63042, +20936, +20937, lateral fusion +63044, 63047, +20938 +63048, 63056, Bone Marrow +63057 Aspiration: +20939 Microdiscectomy: 62380, 63030, Instrumentation: +63035 +22840, +22841, Decompression: +22842, +22845, +22853 +22534, 63005, 63012, ALIF, TLIF, Bone Grafts: Lumbar Fusion +22585, 63017, 63042, PLIF, XLIF, 22614 +20930, +20931, (Multiple Levels) +22614, +63044, 63047, OLIF, Postero- +20936, +20937, +22632, +22634 +63048, 63056, lateral fusion +63057 +20938 Single Level Bone Marrow Fusion: 22533, Aspiration: 22558, 22612, +20939 22630, 22633 Sacroiliac joint Sacroiliac Joint arthrodesis, 27279 27279 Fusion (SIJ)4 Percutaneous SIJ Fusion 4 Effective for dates of service on or after October 1, 2021, NIA will review prior authorization requests for SIJ fusion with use of fixation devices only. Revised 08/2021 3 Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix CERVICAL SPINE SURGERY These codes do not require prior authorization. If the main surgical procedure is Authorization is provided for the primary surgery requested. approved, these codes are There are multiple CPT codes that can be associated with each understood to be procedure. These are assumed to be part of the primary surgery included in request and when completed in combination, do not require a separate conjunction and do prior authorization. not require prior authorization. Note: This is not an all-inclusive list of every ancillary code Primary Primary Primary Additional Ancillary Other Surgery CPT Surgery Covered Procedures / Procedure Request Code Allowable Procedures / Codes Names Billed Codes Groupings Cervical 63075 63075, +63076 Vertebral Instrumentation: Anterior Corpectomy: +22859 Decompression 63081, (without +63082, fusion) 63300, 63304, +63308 Anterior 22551 22548, 22551, Vertebral Instrumentation: ACDF Cervical 22554 Corpectomy: +22845, 22853, Decompression 63081, 22854 with Fusion +63082, Bone Grafts: (Single Level) 63300, 63304, +20930, +20931, +63308 +20936, +20937, Decompressio +20938 n: 63075, +63076 Removal of Artificial Disc: 22864 Anterior 22552 +22552, Vertebral Instrumentation: ACDF Cervical +22585 Corpectomy: +22845, +22846, Decompression 63081, 22853, 22854 with Fusion +63082, Bone Grafts: (Multiple 63300, 63304, 20930, +20931, Levels) +63308 +20936, +20937, Decompressio +20938 n: 63075, Bone Marrow +63076 Aspiration: Single-Level +20939 ACDF: 22548, 22551, 22554 Removal of Artificial Disc: 22864 Revised 08/2021 4 Spinal Conditions Management and Joint Surgery Program Prior Authorization Code Matrix CERVICAL SPINE SURGERY These codes do not require prior authorization. If the main surgical procedure is Authorization is provided for the primary surgery requested. approved, these codes are There are multiple CPT codes that can be associated with each understood to be